Reduction in length of stay for patients undergoing oesophageal and gastric resections with implementation of enhanced recovery packages

Introduction

The high mortality and morbidity associated with resection for oesophagogastric malignancy has resulted in a conservative approach to the postoperative management of this patient group. In August 2009 we introduced an enhanced recovery after surgery (ERAS) pathway tailored to patients undergoing resection for oesophagogastric malignancy. We aimed to assess the impact of this change in practice on standard clinical outcomes.

Methods

Two cohorts were studied of patients undergoing resection for oesophagogastric malignancy before (August 2008 – July 2009) and after (August 2009 – July 2010) the implementation of the ERAS pathway. Data were collected on demographics, interventions, length of stay, morbidity and in-hospital mortality.

Results

There were 53 and 55 oesophagogastric resections undertaken respectively for malignant disease in each of the study periods. The median length of stay for both gastric and oesophageal resection decreased from 15 to 11 days (Mann– Whitney U, p<0.001) following implementation of the ERAS pathway. There was no significant increase in morbidity (gastric resection 23.1% vs 5.3% and oesophageal resection 25.9% vs 16.7%) or mortality (gastric resection no deaths and oesophageal resection 1.8% vs 3.6%) associated with the changes. There was a significant decrease in the number of oral contrast studies used following oesophageal resection, with a reduction from 21 (77.8%) in 2008–2009 to 6 (16.7%) in 2009–2010 (chi-squared test, p<0.0001).

Conclusions

The introduction of an enhanced recovery programme following oesophagogastric surgery resulted in a significant decrease in length of median patient stay in hospital without a significant increase in associated morbidity and mortality.     

Efficiency of liquid tin(ii) n-alkoxide initiators in the ring-opening polymerization of l-lactide: kinetic studies by non-isothermal differential scanning calorimetry

Novel soluble liquid tin(ii) n-butoxide (Sn(OnC₄H₉)₂), tin(ii) n-hexoxide (Sn(OnC₆H₁₃)₂), and tin(ii) n-octoxide (Sn(OnC₈H₁₇)₂) initiators were synthesized for use as coordination–insertion initiators in the bulk ring-opening polymerization (ROP) of l-lactide (LLA). In order to compare their efficiencies with the more commonly used tin(ii) 2-ethylhexanoate (stannous octoate, Sn(Oct)₂) and conventional tin(ii) octoate/n-alcohol (SnOct₂/nROH) initiating systems, kinetic parameters derived from monomer conversion data were obtained from non-isothermal differential scanning calorimetry (DSC). In this work, the three non-isothermal DSC kinetic approaches including dynamic (Kissinger, Flynn–Wall, and Ozawa); isoconversional (Friedman, Kissinger–Akahira–Sunose (KAS) and Ozawa–Flynn–Wall (OFW)); and Borchardt and Daniels (B/D) methods of data analysis were compared. The kinetic results showed that, under the same conditions, the rate of polymerization for the 7 initiators/initiating systems was in the order of liquid Sn(OnC₄H₉)₂ > Sn(Oct)₂/nC₄H₉OH > Sn(Oct)₂ ≅ liquid Sn(OnC₆H₁₃)₂ > Sn(Oct)₂/nC₆H₁₃OH ≅ liquid Sn(OnC₈H₁₇)₂ > Sn(Oct)₂/nC₈H₁₇OH. The lowest activation energies (E_a = 52, 59, and 56 kJ mol⁻¹ for the Kissinger, Flynn–Wall, and Ozawa dynamic methods; E_a = 53–60, 55–58, and 60–62 kJ mol⁻¹ for the Friedman, KAS, and OFW isoconversional methods; and E_a = 76–84 kJ mol⁻¹ for the B/D) were found in the polymerizations using the novel liquid Sn(OnC₄H₉)₂ as the initiator, thereby showing it to be the most efficient initiator in the ROP of l-lactide.

The efficiency of homogeneous liquid tin(ii) n-alkoxide initiators in the ROP of l-lactide was reported in this work by non-isothermal DSC kinetic approaches.     

Conscientiousness and Medication Adherence: A Meta-analysis

Background

Approximately a quarter to a half of all people fail to take their medication regimen as prescribed (i.e. non-adherence). Conscientiousness, from the five-factor model of personality, has been positively linked to adherence to medications in several recent studies.

Purpose

This study aimed to systematically estimate the strength and variability of this association across multiple published articles and to identify moderators of this relationship.

Method

A literature search identified 16 studies (N?=?3,476) that met the study eligibility criteria. Estimates of effect sizes (r) obtained in these studies were meta-analysed.

Results

Overall, a higher level of conscientiousness was associated with better medication adherence (r?=?0.15; 95 % CI, 0.09, 0.21). Associations were significantly stronger in younger samples (r?=?0.26, 95 % CI, 0.17, 0.34; k?=?7).

Conclusion

The small association between conscientiousness and medication adherence may have clinical significance in contexts where small differences in adherence result in clinically important effects.     

Planning and managing a complex multisite study in the age of technology

A 2‐year long, multisite research study that evaluated cardiopulmonary resuscitation skill decay among nursing students was conducted at 10 schools of nursing across the United States. The study was conducted in two phases and required carefully timed sessions for skill performance. Multisite studies in nursing education need to be carefully planned. Time delays should be anticipated with processes and Institutional Review Board protocols across sites. All team members were trained and consistently supported during the entire study. While challenges and obstacles were identified, innovative solutions were implemented that assisted the research team to successfully complete the study. The use of new and existing technology allowed the team to surmount many of the challenges encountered in this study. The purpose of this article is to describe the logistics, processes, challenges, and lessons learned related to conducting a complex multisite study.